request info association executivessite mapabout uscontact us
 Health Insurance Instant Quote 

Click the "Get a Quote" button if you would like to prepare your own health insurance quote, select options and purchase online.   We would advise checking out both health insuance websites as prices vary by state.

   HEALTH COMPARE (wide choice of plans)       ASSURANT HEALTH         MEDICARE SUPPLEMENT

                                                    

 Health Insurance Quote Request 
Please complete the below form to receive your confidential health insurance quotes.

Trade Association Membership (if applicable):
PRIMARY INSURED:
Name:
Telephone:
Email Address:
Address:
City:
State:
Zip Code:
Birth Date:
Height:
Weight:
Smoker Status:
SPOUSE / CHILDREN (IF INCLUDED IN QUOTE):
Spouse Birth Date:
Spouse Height:
Spouse Weight:
Spouse Smoker Status:
Type and Amount:
How many children needing coverage?
ADDITIONAL QUESTIONS:
Does anyone have a serious or chronic condition?
Are you currently covered by health insurance?
Additional comments or quoting instructions:
Do not enter anything in this field:
 

    Your Association Insurance Member Benefits

    © AMJ Insurance, Inc. / Benefit Resourcing / Association Insurance Programs / 2012